Illinois 2025 2025-2026 Regular Session

Illinois House Bill HB1085 Introduced / Bill

Filed 01/08/2025

                    104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED: 5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately. LRB104 05991 BAB 16024 b   A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:  5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11  55 ILCS 5/5-1069.3  65 ILCS 5/10-4-2.3  105 ILCS 5/10-22.3f  215 ILCS 5/370c.3 new  215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately.  LRB104 05991 BAB 16024 b     LRB104 05991 BAB 16024 b   A BILL FOR
104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:
5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11  55 ILCS 5/5-1069.3  65 ILCS 5/10-4-2.3  105 ILCS 5/10-22.3f  215 ILCS 5/370c.3 new  215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/370c.3 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately.
LRB104 05991 BAB 16024 b     LRB104 05991 BAB 16024 b
    LRB104 05991 BAB 16024 b
A BILL FOR
HB1085LRB104 05991 BAB 16024 b   HB1085  LRB104 05991 BAB 16024 b
  HB1085  LRB104 05991 BAB 16024 b
1  AN ACT concerning regulation.
2  Be it enacted by the People of the State of Illinois,
3  represented in the General Assembly:
4  Section 5. The State Employees Group Insurance Act of 1971
5  is amended by changing Section 6.11 as follows:
6  (5 ILCS 375/6.11)
7  Sec. 6.11. Required health benefits; Illinois Insurance
8  Code requirements. The program of health benefits shall
9  provide the post-mastectomy care benefits required to be
10  covered by a policy of accident and health insurance under
11  Section 356t of the Illinois Insurance Code. The program of
12  health benefits shall provide the coverage required under
13  Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10,
14  356w, 356x, 356z.2, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8,
15  356z.9, 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15,
16  356z.17, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
17  356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
18  356z.51, 356z.53, 356z.54, 356z.55, 356z.56, 356z.57, 356z.59,
19  356z.60, 356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and
20  356z.70, and 356z.71, 356z.74, 356z.76, 356z.77, and 356z.80
21  of the Illinois Insurance Code. The program of health benefits
22  must comply with Sections 155.22a, 155.37, 355b, 356z.19,
23  370c, and 370c.1, and 370c.3 and Article XXXIIB of the

 

104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB1085 Introduced , by Rep. Lindsey LaPointe SYNOPSIS AS INTRODUCED:
5 ILCS 375/6.1155 ILCS 5/5-1069.365 ILCS 5/10-4-2.3105 ILCS 5/10-22.3f215 ILCS 5/370c.3 new215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2 5 ILCS 375/6.11  55 ILCS 5/5-1069.3  65 ILCS 5/10-4-2.3  105 ILCS 5/10-22.3f  215 ILCS 5/370c.3 new  215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/370c.3 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2
Amends the Illinois Insurance Code. Establishes reimbursement rates for mental health and substance use disorder treatment services for all group or individual policies of accident and health insurance or managed care plans that are amended, delivered, issued, or renewed on or after January 1, 2027 or for any contracted third party administering the behavioral health benefits for the insurer. Requires a group or individual policy of accident and health insurance or managed care plan that is amended, delivered, issued, or renewed on or after January 1, 2026 or any contracted third party administering the behavioral health benefits for the insurer to cover certain medically necessary mental health and substance use disorder treatment services. Provides that, if the Department of Insurance determines that an insurer or a contracted third party administering the behavioral health benefits for the insurer has violated a provision concerning mental health and substance use parity, the Department shall by order assess a civil penalty of $1,000 for each violation. Excludes certain health care plans serving Medicaid populations who are enrolled under the Illinois Public Aid Code or under the Children's Health Insurance Program Act from provisions concerning mental health and substance use parity. Requires the Department to review the impact of the proposed mental health and substance abuse mandate on network adequacy for mental health and substance use disorder treatment and access to affordable mental health and substance use care. Permits the Department to examine out-of-network utilization and out-of-pocket costs for insureds for mental health and substance use treatment and services for all plans to compare with in-network utilization. Amends the State Employees Group Insurance Act of 1971, the Counties Code, the Illinois Municipal Code, and the School Code to require coverage under those provisions. Effective immediately.
LRB104 05991 BAB 16024 b     LRB104 05991 BAB 16024 b
    LRB104 05991 BAB 16024 b
A BILL FOR

 

 

5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/370c.3 new
215 ILCS 125/5-3 from Ch. 111 1/2, par. 1411.2



    LRB104 05991 BAB 16024 b

 

 



 

  HB1085  LRB104 05991 BAB 16024 b


HB1085- 2 -LRB104 05991 BAB 16024 b   HB1085 - 2 - LRB104 05991 BAB 16024 b
  HB1085 - 2 - LRB104 05991 BAB 16024 b
1  Illinois Insurance Code. The program of health benefits shall
2  provide the coverage required under Section 356m of the
3  Illinois Insurance Code and, for the employees of the State
4  Employee Group Insurance Program only, the coverage as also
5  provided in Section 6.11B of this Act. The Department of
6  Insurance shall enforce the requirements of this Section with
7  respect to Sections 370c, and 370c.1, and 370c.3 of the
8  Illinois Insurance Code; all other requirements of this
9  Section shall be enforced by the Department of Central
10  Management Services.
11  Rulemaking authority to implement Public Act 95-1045, if
12  any, is conditioned on the rules being adopted in accordance
13  with all provisions of the Illinois Administrative Procedure
14  Act and all rules and procedures of the Joint Committee on
15  Administrative Rules; any purported rule not so adopted, for
16  whatever reason, is unauthorized.
17  (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
18  102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
19  1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-768,
20  eff. 1-1-24; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
21  102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
22  1-1-23; 102-1117, eff. 1-13-23; 103-8, eff. 1-1-24; 103-84,
23  eff. 1-1-24; 103-91, eff. 1-1-24; 103-420, eff. 1-1-24;
24  103-445, eff. 1-1-24; 103-535, eff. 8-11-23; 103-551, eff.
25  8-11-23; 103-605, eff. 7-1-24; 103-718, eff. 7-19-24; 103-751,
26  eff. 8-2-24; 103-870, eff. 1-1-25; 103-914, eff. 1-1-25;

 

 

  HB1085 - 2 - LRB104 05991 BAB 16024 b


HB1085- 3 -LRB104 05991 BAB 16024 b   HB1085 - 3 - LRB104 05991 BAB 16024 b
  HB1085 - 3 - LRB104 05991 BAB 16024 b
1  103-918, eff. 1-1-25; 103-951, eff. 1-1-25; 103-1024, eff.
2  1-1-25; revised 11-26-24.)
3  Section 10. The Counties Code is amended by changing
4  Section 5-1069.3 as follows:
5  (55 ILCS 5/5-1069.3)
6  Sec. 5-1069.3. Required health benefits. If a county,
7  including a home rule county, is a self-insurer for purposes
8  of providing health insurance coverage for its employees, the
9  coverage shall include coverage for the post-mastectomy care
10  benefits required to be covered by a policy of accident and
11  health insurance under Section 356t and the coverage required
12  under Sections 356g, 356g.5, 356g.5-1, 356m, 356q, 356u,
13  356u.10, 356w, 356x, 356z.4, 356z.4a, 356z.6, 356z.8, 356z.9,
14  356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.22,
15  356z.25, 356z.26, 356z.29, 356z.30, 356z.32, 356z.33, 356z.36,
16  356z.40, 356z.41, 356z.45, 356z.46, 356z.47, 356z.48, 356z.51,
17  356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61,
18  356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and 356z.71,
19  356z.74, 356z.77, and 356z.80 of the Illinois Insurance Code.
20  The coverage shall comply with Sections 155.22a, 355b,
21  356z.19, and 370c, and 370c.3 of the Illinois Insurance Code.
22  The Department of Insurance shall enforce the requirements of
23  this Section. The requirement that health benefits be covered
24  as provided in this Section is an exclusive power and function

 

 

  HB1085 - 3 - LRB104 05991 BAB 16024 b


HB1085- 4 -LRB104 05991 BAB 16024 b   HB1085 - 4 - LRB104 05991 BAB 16024 b
  HB1085 - 4 - LRB104 05991 BAB 16024 b
1  of the State and is a denial and limitation under Article VII,
2  Section 6, subsection (h) of the Illinois Constitution. A home
3  rule county to which this Section applies must comply with
4  every provision of this Section.
5  Rulemaking authority to implement Public Act 95-1045, if
6  any, is conditioned on the rules being adopted in accordance
7  with all provisions of the Illinois Administrative Procedure
8  Act and all rules and procedures of the Joint Committee on
9  Administrative Rules; any purported rule not so adopted, for
10  whatever reason, is unauthorized.
11  (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
12  102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
13  1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
14  eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
15  102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
16  1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
17  eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
18  103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
19  7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
20  eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
21  revised 11-26-24.)
22  Section 15. The Illinois Municipal Code is amended by
23  changing Section 10-4-2.3 as follows:
24  (65 ILCS 5/10-4-2.3)

 

 

  HB1085 - 4 - LRB104 05991 BAB 16024 b


HB1085- 5 -LRB104 05991 BAB 16024 b   HB1085 - 5 - LRB104 05991 BAB 16024 b
  HB1085 - 5 - LRB104 05991 BAB 16024 b
1  Sec. 10-4-2.3. Required health benefits. If a
2  municipality, including a home rule municipality, is a
3  self-insurer for purposes of providing health insurance
4  coverage for its employees, the coverage shall include
5  coverage for the post-mastectomy care benefits required to be
6  covered by a policy of accident and health insurance under
7  Section 356t and the coverage required under Sections 356g,
8  356g.5, 356g.5-1, 356m, 356q, 356u, 356u.10, 356w, 356x,
9  356z.4, 356z.4a, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11,
10  356z.12, 356z.13, 356z.14, 356z.15, 356z.22, 356z.25, 356z.26,
11  356z.29, 356z.30, 356z.32, 356z.33, 356z.36, 356z.40, 356z.41,
12  356z.45, 356z.46, 356z.47, 356z.48, 356z.51, 356z.53, 356z.54,
13  356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62, 356z.64,
14  356z.67, 356z.68, and 356z.70, and 356z.71, 356z.74, 356z.77,
15  and 356z.80 of the Illinois Insurance Code. The coverage shall
16  comply with Sections 155.22a, 355b, 356z.19, and 370c, and
17  370c.3 of the Illinois Insurance Code. The Department of
18  Insurance shall enforce the requirements of this Section. The
19  requirement that health benefits be covered as provided in
20  this is an exclusive power and function of the State and is a
21  denial and limitation under Article VII, Section 6, subsection
22  (h) of the Illinois Constitution. A home rule municipality to
23  which this Section applies must comply with every provision of
24  this Section.
25  Rulemaking authority to implement Public Act 95-1045, if
26  any, is conditioned on the rules being adopted in accordance

 

 

  HB1085 - 5 - LRB104 05991 BAB 16024 b


HB1085- 6 -LRB104 05991 BAB 16024 b   HB1085 - 6 - LRB104 05991 BAB 16024 b
  HB1085 - 6 - LRB104 05991 BAB 16024 b
1  with all provisions of the Illinois Administrative Procedure
2  Act and all rules and procedures of the Joint Committee on
3  Administrative Rules; any purported rule not so adopted, for
4  whatever reason, is unauthorized.
5  (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
6  102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
7  1-1-22; 102-642, eff. 1-1-22; 102-665, eff. 10-8-21; 102-731,
8  eff. 1-1-23; 102-804, eff. 1-1-23; 102-813, eff. 5-13-22;
9  102-816, eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff.
10  1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91,
11  eff. 1-1-24; 103-420, eff. 1-1-24; 103-445, eff. 1-1-24;
12  103-535, eff. 8-11-23; 103-551, eff. 8-11-23; 103-605, eff.
13  7-1-24; 103-718, eff. 7-19-24; 103-751, eff. 8-2-24; 103-914,
14  eff. 1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25;
15  revised 11-26-24.)
16  Section 20. The School Code is amended by changing Section
17  10-22.3f as follows:
18  (105 ILCS 5/10-22.3f)
19  Sec. 10-22.3f. Required health benefits. Insurance
20  protection and benefits for employees shall provide the
21  post-mastectomy care benefits required to be covered by a
22  policy of accident and health insurance under Section 356t and
23  the coverage required under Sections 356g, 356g.5, 356g.5-1,
24  356m, 356q, 356u, 356u.10, 356w, 356x, 356z.4, 356z.4a,

 

 

  HB1085 - 6 - LRB104 05991 BAB 16024 b


HB1085- 7 -LRB104 05991 BAB 16024 b   HB1085 - 7 - LRB104 05991 BAB 16024 b
  HB1085 - 7 - LRB104 05991 BAB 16024 b
1  356z.6, 356z.8, 356z.9, 356z.11, 356z.12, 356z.13, 356z.14,
2  356z.15, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30, 356z.32,
3  356z.33, 356z.36, 356z.40, 356z.41, 356z.45, 356z.46, 356z.47,
4  356z.51, 356z.53, 356z.54, 356z.56, 356z.57, 356z.59, 356z.60,
5  356z.61, 356z.62, 356z.64, 356z.67, 356z.68, and 356z.70, and
6  356z.71, 356z.74, 356z.77, and 356z.80 of the Illinois
7  Insurance Code. Insurance policies shall comply with Section
8  356z.19 of the Illinois Insurance Code. The coverage shall
9  comply with Sections 155.22a, 355b, and 370c, and 370c.3 of
10  the Illinois Insurance Code. The Department of Insurance shall
11  enforce the requirements of this Section.
12  Rulemaking authority to implement Public Act 95-1045, if
13  any, is conditioned on the rules being adopted in accordance
14  with all provisions of the Illinois Administrative Procedure
15  Act and all rules and procedures of the Joint Committee on
16  Administrative Rules; any purported rule not so adopted, for
17  whatever reason, is unauthorized.
18  (Source: P.A. 102-30, eff. 1-1-22; 102-103, eff. 1-1-22;
19  102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-642, eff.
20  1-1-22; 102-665, eff. 10-8-21; 102-731, eff. 1-1-23; 102-804,
21  eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff. 1-1-23;
22  102-860, eff. 1-1-23; 102-1093, eff. 1-1-23; 102-1117, eff.
23  1-13-23; 103-84, eff. 1-1-24; 103-91, eff. 1-1-24; 103-420,
24  eff. 1-1-24; 103-445, eff. 1-1-24; 103-535, eff. 8-11-23;
25  103-551, eff. 8-11-23; 103-605, eff. 7-1-24; 103-718, eff.
26  7-19-24; 103-751, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918,

 

 

  HB1085 - 7 - LRB104 05991 BAB 16024 b


HB1085- 8 -LRB104 05991 BAB 16024 b   HB1085 - 8 - LRB104 05991 BAB 16024 b
  HB1085 - 8 - LRB104 05991 BAB 16024 b
1  eff. 1-1-25; 103-1024, eff. 1-1-25; revised 11-26-24.)
2  Section 25. The Illinois Insurance Code is amended by
3  adding Section 370c.3 as follows:
4  (215 ILCS 5/370c.3 new)
5  Sec. 370c.3. Mental health and substance use parity.
6  (a) In this Section:
7  "Application" means a person's or facility's application
8  to become a participating provider with an insurer in at least
9  one of the insurer's provider networks.
10  "Applying provider" means a provider or facility that has
11  submitted a completed application to become a participating
12  provider or facility with an insurer.
13  "Behavioral health trainee" means any person: (1) engaged
14  in the provision of mental health or substance use disorder
15  clinical services as part of that person's supervised course
16  of study while enrolled in a master's or doctoral psychology,
17  social work, counseling, or marriage or family therapy program
18  or as a postdoctoral graduate working toward licensure; and
19  (2) who is working toward clinical State licensure under the
20  clinical supervision of a fully licensed mental health or
21  substance use disorder treatment provider.
22  "Completed application" means a person's or facility's
23  application to become a participating provider that has been
24  submitted to the insurer and includes all the required

 

 

  HB1085 - 8 - LRB104 05991 BAB 16024 b


HB1085- 9 -LRB104 05991 BAB 16024 b   HB1085 - 9 - LRB104 05991 BAB 16024 b
  HB1085 - 9 - LRB104 05991 BAB 16024 b
1  information for the application to be considered by the
2  insurer according to the insurer's policies and procedures for
3  verifying a provider's or facility's credentials.
4  "Contracting process" means the process by which a mental
5  health or substance use disorder treatment provider or
6  facility makes a completed application with an insurer to
7  become a participating provider with the insurer until the
8  effective date of a final contract between the provider or
9  facility and the insurer. "Contracting process" includes the
10  process of verifying a provider's credentials.
11  "Participating provider" means any mental health or
12  substance use disorder treatment provider that has a contract
13  to provide mental health or substance use disorder services
14  with an insurer.
15  (b) For all group or individual policies of accident and
16  health insurance or managed care plans that are amended,
17  delivered, issued, or renewed on or after January 1, 2027, or
18  any contracted third party administering the behavioral health
19  benefits for the insurer, reimbursement for in-network mental
20  health and substance use disorder treatment services delivered
21  by Illinois providers and facilities must be equal to or
22  greater than 141% of the Medicare rate for the mental health or
23  substance use disorder service delivered. For services not
24  covered by Medicare, the reimbursement rates must be, on
25  average, equal to or greater than 144% of the insurer's
26  in-network reimbursement rate for such service on the

 

 

  HB1085 - 9 - LRB104 05991 BAB 16024 b


HB1085- 10 -LRB104 05991 BAB 16024 b   HB1085 - 10 - LRB104 05991 BAB 16024 b
  HB1085 - 10 - LRB104 05991 BAB 16024 b
1  effective date of this amendatory Act of the 104th General
2  Assembly. This Section applies to all covered office,
3  outpatient, inpatient, and residential mental health and
4  substance use disorder services. If at any time the average
5  reimbursement for in-network medical or surgical services
6  delivered by Illinois providers exceeds 141% of the Medicare
7  rate for such services, then the reimbursement for mental
8  health and substance use disorder treatment services must be
9  equal to or greater than that average.
10  This Section applies to all covered office, outpatient,
11  inpatient, and residential mental health and substance use
12  disorder services.
13  This subsection does not apply to mental health or
14  substance use disorder services provided by a hospital when
15  the hospital has a contract with the insurer that provides for
16  reimbursement for such services based on achieving specified
17  patient health outcomes and other quality measures and
18  includes shared savings from lower health care costs.
19  (c) A group or individual policy of accident and health
20  insurance or managed care plan that is amended, delivered,
21  issued, or renewed on or after January 1, 2026, or contracted
22  third party administering the behavioral health benefits for
23  the insurer, shall cover all medically necessary mental health
24  or substance use disorder services received by the same
25  insured on the same day from the same or different mental
26  health or substance use provider or facility for both

 

 

  HB1085 - 10 - LRB104 05991 BAB 16024 b


HB1085- 11 -LRB104 05991 BAB 16024 b   HB1085 - 11 - LRB104 05991 BAB 16024 b
  HB1085 - 11 - LRB104 05991 BAB 16024 b
1  outpatient and inpatient care.
2  (d) A group or individual policy of accident and health
3  insurance or managed care plan that is amended, delivered,
4  issued, or renewed on or after January 1, 2026, or any
5  contracted third party administering the behavioral health
6  benefits for the insurer, shall cover any medically necessary
7  mental health or substance use disorder service provided by a
8  behavioral health trainee when the trainee is working toward
9  clinical State licensure and is under the supervision of a
10  fully licensed mental health or substance use disorder
11  treatment provider, which is a physician licensed to practice
12  medicine in all its branches, licensed clinical psychologist,
13  licensed clinical social worker, licensed clinical
14  professional counselor, licensed marriage and family
15  therapist, licensed speech-language pathologist, or other
16  licensed or certified professional at a program licensed
17  pursuant to the Substance Use Disorder Act who is engaged in
18  treating mental, emotional, nervous, or substance use
19  disorders or conditions. Services provided by the trainee must
20  be billed under the supervising clinician's rendering National
21  Provider Identifier.
22  (e) A group or individual policy of accident and health
23  insurance or managed care plan that is amended, delivered,
24  issued, or renewed on or after January 1, 2026, or any
25  contracted third party administering the behavioral health
26  benefits for the insurer, shall:

 

 

  HB1085 - 11 - LRB104 05991 BAB 16024 b


HB1085- 12 -LRB104 05991 BAB 16024 b   HB1085 - 12 - LRB104 05991 BAB 16024 b
  HB1085 - 12 - LRB104 05991 BAB 16024 b
1  (1) cover medically necessary 60-minute psychotherapy
2  billed using the CPT Code 90837 for Individual Therapy;
3  (2) not impose more onerous documentation requirements
4  on the provider than is required for other psychotherapy
5  CPT Codes; and
6  (3) not audit the use of CPT Code 90837 any more
7  frequently than audits for the use of other psychotherapy
8  CPT Codes.
9  (f)(1) Any group or individual policy of accident and
10  health insurance or managed care plan that is amended,
11  delivered, issued, or renewed on or after January 1, 2026, or
12  any contracted third party administering the behavioral health
13  benefits for the insurer, shall complete the contracting
14  process with a mental health or substance use disorder
15  treatment provider or facility for becoming a participating
16  provider in the insurer's network, including the verification
17  of the provider's credentials, within 60 days from the date of
18  a completed application to the insurer to become a
19  participating provider. Nothing in this paragraph (1),
20  however, presumes or establishes a contract between an insurer
21  and a provider.
22  (2) Any group or individual policy of accident and health
23  insurance or managed care plan that is amended, delivered,
24  issued, or renewed on or after January 1, 2026, or any
25  contracted third party administering the behavioral health
26  benefits for the insurer, shall reimburse a participating

 

 

  HB1085 - 12 - LRB104 05991 BAB 16024 b


HB1085- 13 -LRB104 05991 BAB 16024 b   HB1085 - 13 - LRB104 05991 BAB 16024 b
  HB1085 - 13 - LRB104 05991 BAB 16024 b
1  mental health or substance use disorder treatment provider or
2  facility at the contracted reimbursement rate for any
3  medically necessary services provided to an insured from the
4  date of submission of the provider's or facility's completed
5  application to become a participating provider with the
6  insurer up to the effective date of the provider's contract.
7  The provider's claims for such services shall be reimbursed
8  only when submitted after the effective date of the provider's
9  contract with the insurer. This paragraph (2) does not apply
10  to a provider that does not have a completed contract with an
11  insurer. If a provider opts to submit claims for medically
12  necessary mental health or substance use disorder services
13  pursuant to this paragraph (2), the provider must notify the
14  insured following submission of the claims to the insurer that
15  the services provided to the insured may be treated as
16  in-network services.
17  (3) Any group or individual policy of accident and health
18  insurance or managed care plan that is amended, delivered,
19  issued, or renewed on or after January 1, 2026, or any
20  contracted third party administering the behavioral health
21  benefits for the insurer, shall cover any medically necessary
22  mental health or substance use disorder service provided by a
23  fully licensed mental health or substance use disorder
24  treatment provider affiliated with a mental health or
25  substance use disorder treatment group practice who has
26  submitted a completed application to become a participating

 

 

  HB1085 - 13 - LRB104 05991 BAB 16024 b


HB1085- 14 -LRB104 05991 BAB 16024 b   HB1085 - 14 - LRB104 05991 BAB 16024 b
  HB1085 - 14 - LRB104 05991 BAB 16024 b
1  provider with an insurer who is delivering services under the
2  supervision of another fully licensed participating mental
3  health or substance use disorder treatment provider within the
4  same group practice up to the effective date of the applying
5  provider's contract with the insurer as a participating
6  provider. Services provided by the applying provider must be
7  billed under the supervising licensed provider's rendering
8  National Provider Identifier.
9  (4) Upon request, an insurer, or any contracted third
10  party administering the behavioral health benefits for the
11  insurer, shall provide an applying provider with the insurer's
12  credentialing policies and procedures. An insurer, or any
13  contracted third party administering the behavioral health
14  benefits for the insurer, shall post the following
15  nonproprietary information on its website and make that
16  information available to all applicants:
17  (A) a list of the information required to be included
18  in an application;
19  (B) a checklist of the materials that must be
20  submitted in the credentialing process; and
21  (C) designated contact information of a network
22  representative, including a designated point of contact,
23  an email address, and a telephone number, to which an
24  applicant may address any credentialing inquiries.
25  (g) The Department has the same authority to enforce this
26  Section as it has to enforce compliance with Sections 370c and

 

 

  HB1085 - 14 - LRB104 05991 BAB 16024 b


HB1085- 15 -LRB104 05991 BAB 16024 b   HB1085 - 15 - LRB104 05991 BAB 16024 b
  HB1085 - 15 - LRB104 05991 BAB 16024 b
1  370c.1. Additionally, if the Department determines that an
2  insurer or a contracted third party administering the
3  behavioral health benefits for the insurer has violated this
4  Section, the Department shall, after appropriate notice and
5  opportunity for hearing in accordance with Section 402, by
6  order assess a civil penalty of $1,000 for each violation. The
7  Department shall establish any processes or procedures
8  necessary to monitor compliance with this Section.
9  (h) At the end of 5 years, 10 years, and 15 years following
10  the implementation of subsection (b) of this Section, the
11  Department shall review the impact of this Section on network
12  adequacy for mental health and substance use disorder
13  treatment and access to affordable mental health and substance
14  use care. By no later than December 31, 2033, December 31,
15  2038, and December 31, 2043, the Department shall submit a
16  report in each of those years to the General Assembly that
17  includes its analyses and findings. For the purpose of
18  evaluating trends in network adequacy, the Department may
19  examine out-of-network utilization and out-of-pocket costs for
20  insureds for mental health and substance use treatment and
21  services for all plans to compare with in-network utilization.
22  (i) The Department shall adopt any rules necessary to
23  implement this Section by no later than May 1, 2026.
24  (j) This Section does not apply to a health care plan
25  serving Medicaid populations that provides, arranges for, pays
26  for, or reimburses the cost of any health care service for

 

 

  HB1085 - 15 - LRB104 05991 BAB 16024 b


HB1085- 16 -LRB104 05991 BAB 16024 b   HB1085 - 16 - LRB104 05991 BAB 16024 b
  HB1085 - 16 - LRB104 05991 BAB 16024 b
1  persons who are enrolled under the Illinois Public Aid Code or
2  under the Children's Health Insurance Program Act.
3  Section 30. The Health Maintenance Organization Act is
4  amended by changing Section 5-3 as follows:
5  (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
6  (Text of Section before amendment by P.A. 103-808)
7  Sec. 5-3. Insurance Code provisions.
8  (a) Health Maintenance Organizations shall be subject to
9  the provisions of Sections 133, 134, 136, 137, 139, 140,
10  141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
11  152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
12  155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g.5-1,
13  356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2, 356z.3a,
14  356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9, 356z.10,
15  356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, 356z.18,
16  356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24, 356z.25,
17  356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32, 356z.33,
18  356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39, 356z.40,
19  356z.40a, 356z.41, 356z.44, 356z.45, 356z.46, 356z.47,
20  356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54, 356z.55,
21  356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61, 356z.62,
22  356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68, 356z.69,
23  356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75, 356z.77,
24  356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i, 368a, 368b,

 

 

  HB1085 - 16 - LRB104 05991 BAB 16024 b


HB1085- 17 -LRB104 05991 BAB 16024 b   HB1085 - 17 - LRB104 05991 BAB 16024 b
  HB1085 - 17 - LRB104 05991 BAB 16024 b
1  368c, 368d, 368e, 370c, 370c.1, 370c.3, 401, 401.1, 402, 403,
2  403A, 408, 408.2, 409, 412, 444, and 444.1, paragraph (c) of
3  subsection (2) of Section 367, and Articles IIA, VIII 1/2,
4  XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and XXXIIB of the
5  Illinois Insurance Code.
6  (b) For purposes of the Illinois Insurance Code, except
7  for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
8  Health Maintenance Organizations in the following categories
9  are deemed to be "domestic companies":
10  (1) a corporation authorized under the Dental Service
11  Plan Act or the Voluntary Health Services Plans Act;
12  (2) a corporation organized under the laws of this
13  State; or
14  (3) a corporation organized under the laws of another
15  state, 30% or more of the enrollees of which are residents
16  of this State, except a corporation subject to
17  substantially the same requirements in its state of
18  organization as is a "domestic company" under Article VIII
19  1/2 of the Illinois Insurance Code.
20  (c) In considering the merger, consolidation, or other
21  acquisition of control of a Health Maintenance Organization
22  pursuant to Article VIII 1/2 of the Illinois Insurance Code,
23  (1) the Director shall give primary consideration to
24  the continuation of benefits to enrollees and the
25  financial conditions of the acquired Health Maintenance
26  Organization after the merger, consolidation, or other

 

 

  HB1085 - 17 - LRB104 05991 BAB 16024 b


HB1085- 18 -LRB104 05991 BAB 16024 b   HB1085 - 18 - LRB104 05991 BAB 16024 b
  HB1085 - 18 - LRB104 05991 BAB 16024 b
1  acquisition of control takes effect;
2  (2)(i) the criteria specified in subsection (1)(b) of
3  Section 131.8 of the Illinois Insurance Code shall not
4  apply and (ii) the Director, in making his determination
5  with respect to the merger, consolidation, or other
6  acquisition of control, need not take into account the
7  effect on competition of the merger, consolidation, or
8  other acquisition of control;
9  (3) the Director shall have the power to require the
10  following information:
11  (A) certification by an independent actuary of the
12  adequacy of the reserves of the Health Maintenance
13  Organization sought to be acquired;
14  (B) pro forma financial statements reflecting the
15  combined balance sheets of the acquiring company and
16  the Health Maintenance Organization sought to be
17  acquired as of the end of the preceding year and as of
18  a date 90 days prior to the acquisition, as well as pro
19  forma financial statements reflecting projected
20  combined operation for a period of 2 years;
21  (C) a pro forma business plan detailing an
22  acquiring party's plans with respect to the operation
23  of the Health Maintenance Organization sought to be
24  acquired for a period of not less than 3 years; and
25  (D) such other information as the Director shall
26  require.

 

 

  HB1085 - 18 - LRB104 05991 BAB 16024 b


HB1085- 19 -LRB104 05991 BAB 16024 b   HB1085 - 19 - LRB104 05991 BAB 16024 b
  HB1085 - 19 - LRB104 05991 BAB 16024 b
1  (d) The provisions of Article VIII 1/2 of the Illinois
2  Insurance Code and this Section 5-3 shall apply to the sale by
3  any health maintenance organization of greater than 10% of its
4  enrollee population (including, without limitation, the health
5  maintenance organization's right, title, and interest in and
6  to its health care certificates).
7  (e) In considering any management contract or service
8  agreement subject to Section 141.1 of the Illinois Insurance
9  Code, the Director (i) shall, in addition to the criteria
10  specified in Section 141.2 of the Illinois Insurance Code,
11  take into account the effect of the management contract or
12  service agreement on the continuation of benefits to enrollees
13  and the financial condition of the health maintenance
14  organization to be managed or serviced, and (ii) need not take
15  into account the effect of the management contract or service
16  agreement on competition.
17  (f) Except for small employer groups as defined in the
18  Small Employer Rating, Renewability and Portability Health
19  Insurance Act and except for medicare supplement policies as
20  defined in Section 363 of the Illinois Insurance Code, a
21  Health Maintenance Organization may by contract agree with a
22  group or other enrollment unit to effect refunds or charge
23  additional premiums under the following terms and conditions:
24  (i) the amount of, and other terms and conditions with
25  respect to, the refund or additional premium are set forth
26  in the group or enrollment unit contract agreed in advance

 

 

  HB1085 - 19 - LRB104 05991 BAB 16024 b


HB1085- 20 -LRB104 05991 BAB 16024 b   HB1085 - 20 - LRB104 05991 BAB 16024 b
  HB1085 - 20 - LRB104 05991 BAB 16024 b
1  of the period for which a refund is to be paid or
2  additional premium is to be charged (which period shall
3  not be less than one year); and
4  (ii) the amount of the refund or additional premium
5  shall not exceed 20% of the Health Maintenance
6  Organization's profitable or unprofitable experience with
7  respect to the group or other enrollment unit for the
8  period (and, for purposes of a refund or additional
9  premium, the profitable or unprofitable experience shall
10  be calculated taking into account a pro rata share of the
11  Health Maintenance Organization's administrative and
12  marketing expenses, but shall not include any refund to be
13  made or additional premium to be paid pursuant to this
14  subsection (f)). The Health Maintenance Organization and
15  the group or enrollment unit may agree that the profitable
16  or unprofitable experience may be calculated taking into
17  account the refund period and the immediately preceding 2
18  plan years.
19  The Health Maintenance Organization shall include a
20  statement in the evidence of coverage issued to each enrollee
21  describing the possibility of a refund or additional premium,
22  and upon request of any group or enrollment unit, provide to
23  the group or enrollment unit a description of the method used
24  to calculate (1) the Health Maintenance Organization's
25  profitable experience with respect to the group or enrollment
26  unit and the resulting refund to the group or enrollment unit

 

 

  HB1085 - 20 - LRB104 05991 BAB 16024 b


HB1085- 21 -LRB104 05991 BAB 16024 b   HB1085 - 21 - LRB104 05991 BAB 16024 b
  HB1085 - 21 - LRB104 05991 BAB 16024 b
1  or (2) the Health Maintenance Organization's unprofitable
2  experience with respect to the group or enrollment unit and
3  the resulting additional premium to be paid by the group or
4  enrollment unit.
5  In no event shall the Illinois Health Maintenance
6  Organization Guaranty Association be liable to pay any
7  contractual obligation of an insolvent organization to pay any
8  refund authorized under this Section.
9  (g) Rulemaking authority to implement Public Act 95-1045,
10  if any, is conditioned on the rules being adopted in
11  accordance with all provisions of the Illinois Administrative
12  Procedure Act and all rules and procedures of the Joint
13  Committee on Administrative Rules; any purported rule not so
14  adopted, for whatever reason, is unauthorized.
15  (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
16  102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
17  1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
18  eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
19  102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
20  1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
21  eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
22  103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
23  6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
24  eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
25  103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
26  1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,

 

 

  HB1085 - 21 - LRB104 05991 BAB 16024 b


HB1085- 22 -LRB104 05991 BAB 16024 b   HB1085 - 22 - LRB104 05991 BAB 16024 b
  HB1085 - 22 - LRB104 05991 BAB 16024 b
1  eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
2  103-777, eff. 8-2-24; 103-914, eff. 1-1-25; 103-918, eff.
3  1-1-25; 103-1024, eff. 1-1-25; revised 9-26-24.)
4  (Text of Section after amendment by P.A. 103-808)
5  Sec. 5-3. Insurance Code provisions.
6  (a) Health Maintenance Organizations shall be subject to
7  the provisions of Sections 133, 134, 136, 137, 139, 140,
8  141.1, 141.2, 141.3, 143, 143.31, 143c, 147, 148, 149, 151,
9  152, 153, 154, 154.5, 154.6, 154.7, 154.8, 155.04, 155.22a,
10  155.49, 352c, 355.2, 355.3, 355.6, 355b, 355c, 356f, 356g,
11  356g.5-1, 356m, 356q, 356u.10, 356v, 356w, 356x, 356z.2,
12  356z.3a, 356z.4, 356z.4a, 356z.5, 356z.6, 356z.8, 356z.9,
13  356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17,
14  356z.18, 356z.19, 356z.20, 356z.21, 356z.22, 356z.23, 356z.24,
15  356z.25, 356z.26, 356z.28, 356z.29, 356z.30, 356z.31, 356z.32,
16  356z.33, 356z.34, 356z.35, 356z.36, 356z.37, 356z.38, 356z.39,
17  356z.40, 356z.40a, 356z.41, 356z.44, 356z.45, 356z.46,
18  356z.47, 356z.48, 356z.49, 356z.50, 356z.51, 356z.53, 356z.54,
19  356z.55, 356z.56, 356z.57, 356z.58, 356z.59, 356z.60, 356z.61,
20  356z.62, 356z.63, 356z.64, 356z.65, 356z.66, 356z.67, 356z.68,
21  356z.69, 356z.70, 356z.71, 356z.72, 356z.73, 356z.74, 356z.75,
22  356z.77, 356z.80, 364, 364.01, 364.3, 367.2, 367.2-5, 367i,
23  368a, 368b, 368c, 368d, 368e, 370c, 370c.1, 370c.3, 401,
24  401.1, 402, 403, 403A, 408, 408.2, 409, 412, 444, and 444.1,
25  paragraph (c) of subsection (2) of Section 367, and Articles

 

 

  HB1085 - 22 - LRB104 05991 BAB 16024 b


HB1085- 23 -LRB104 05991 BAB 16024 b   HB1085 - 23 - LRB104 05991 BAB 16024 b
  HB1085 - 23 - LRB104 05991 BAB 16024 b
1  IIA, VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, XXVI, and
2  XXXIIB of the Illinois Insurance Code.
3  (b) For purposes of the Illinois Insurance Code, except
4  for Sections 444 and 444.1 and Articles XIII and XIII 1/2,
5  Health Maintenance Organizations in the following categories
6  are deemed to be "domestic companies":
7  (1) a corporation authorized under the Dental Service
8  Plan Act or the Voluntary Health Services Plans Act;
9  (2) a corporation organized under the laws of this
10  State; or
11  (3) a corporation organized under the laws of another
12  state, 30% or more of the enrollees of which are residents
13  of this State, except a corporation subject to
14  substantially the same requirements in its state of
15  organization as is a "domestic company" under Article VIII
16  1/2 of the Illinois Insurance Code.
17  (c) In considering the merger, consolidation, or other
18  acquisition of control of a Health Maintenance Organization
19  pursuant to Article VIII 1/2 of the Illinois Insurance Code,
20  (1) the Director shall give primary consideration to
21  the continuation of benefits to enrollees and the
22  financial conditions of the acquired Health Maintenance
23  Organization after the merger, consolidation, or other
24  acquisition of control takes effect;
25  (2)(i) the criteria specified in subsection (1)(b) of
26  Section 131.8 of the Illinois Insurance Code shall not

 

 

  HB1085 - 23 - LRB104 05991 BAB 16024 b


HB1085- 24 -LRB104 05991 BAB 16024 b   HB1085 - 24 - LRB104 05991 BAB 16024 b
  HB1085 - 24 - LRB104 05991 BAB 16024 b
1  apply and (ii) the Director, in making his determination
2  with respect to the merger, consolidation, or other
3  acquisition of control, need not take into account the
4  effect on competition of the merger, consolidation, or
5  other acquisition of control;
6  (3) the Director shall have the power to require the
7  following information:
8  (A) certification by an independent actuary of the
9  adequacy of the reserves of the Health Maintenance
10  Organization sought to be acquired;
11  (B) pro forma financial statements reflecting the
12  combined balance sheets of the acquiring company and
13  the Health Maintenance Organization sought to be
14  acquired as of the end of the preceding year and as of
15  a date 90 days prior to the acquisition, as well as pro
16  forma financial statements reflecting projected
17  combined operation for a period of 2 years;
18  (C) a pro forma business plan detailing an
19  acquiring party's plans with respect to the operation
20  of the Health Maintenance Organization sought to be
21  acquired for a period of not less than 3 years; and
22  (D) such other information as the Director shall
23  require.
24  (d) The provisions of Article VIII 1/2 of the Illinois
25  Insurance Code and this Section 5-3 shall apply to the sale by
26  any health maintenance organization of greater than 10% of its

 

 

  HB1085 - 24 - LRB104 05991 BAB 16024 b


HB1085- 25 -LRB104 05991 BAB 16024 b   HB1085 - 25 - LRB104 05991 BAB 16024 b
  HB1085 - 25 - LRB104 05991 BAB 16024 b
1  enrollee population (including, without limitation, the health
2  maintenance organization's right, title, and interest in and
3  to its health care certificates).
4  (e) In considering any management contract or service
5  agreement subject to Section 141.1 of the Illinois Insurance
6  Code, the Director (i) shall, in addition to the criteria
7  specified in Section 141.2 of the Illinois Insurance Code,
8  take into account the effect of the management contract or
9  service agreement on the continuation of benefits to enrollees
10  and the financial condition of the health maintenance
11  organization to be managed or serviced, and (ii) need not take
12  into account the effect of the management contract or service
13  agreement on competition.
14  (f) Except for small employer groups as defined in the
15  Small Employer Rating, Renewability and Portability Health
16  Insurance Act and except for medicare supplement policies as
17  defined in Section 363 of the Illinois Insurance Code, a
18  Health Maintenance Organization may by contract agree with a
19  group or other enrollment unit to effect refunds or charge
20  additional premiums under the following terms and conditions:
21  (i) the amount of, and other terms and conditions with
22  respect to, the refund or additional premium are set forth
23  in the group or enrollment unit contract agreed in advance
24  of the period for which a refund is to be paid or
25  additional premium is to be charged (which period shall
26  not be less than one year); and

 

 

  HB1085 - 25 - LRB104 05991 BAB 16024 b


HB1085- 26 -LRB104 05991 BAB 16024 b   HB1085 - 26 - LRB104 05991 BAB 16024 b
  HB1085 - 26 - LRB104 05991 BAB 16024 b
1  (ii) the amount of the refund or additional premium
2  shall not exceed 20% of the Health Maintenance
3  Organization's profitable or unprofitable experience with
4  respect to the group or other enrollment unit for the
5  period (and, for purposes of a refund or additional
6  premium, the profitable or unprofitable experience shall
7  be calculated taking into account a pro rata share of the
8  Health Maintenance Organization's administrative and
9  marketing expenses, but shall not include any refund to be
10  made or additional premium to be paid pursuant to this
11  subsection (f)). The Health Maintenance Organization and
12  the group or enrollment unit may agree that the profitable
13  or unprofitable experience may be calculated taking into
14  account the refund period and the immediately preceding 2
15  plan years.
16  The Health Maintenance Organization shall include a
17  statement in the evidence of coverage issued to each enrollee
18  describing the possibility of a refund or additional premium,
19  and upon request of any group or enrollment unit, provide to
20  the group or enrollment unit a description of the method used
21  to calculate (1) the Health Maintenance Organization's
22  profitable experience with respect to the group or enrollment
23  unit and the resulting refund to the group or enrollment unit
24  or (2) the Health Maintenance Organization's unprofitable
25  experience with respect to the group or enrollment unit and
26  the resulting additional premium to be paid by the group or

 

 

  HB1085 - 26 - LRB104 05991 BAB 16024 b


HB1085- 27 -LRB104 05991 BAB 16024 b   HB1085 - 27 - LRB104 05991 BAB 16024 b
  HB1085 - 27 - LRB104 05991 BAB 16024 b
1  enrollment unit.
2  In no event shall the Illinois Health Maintenance
3  Organization Guaranty Association be liable to pay any
4  contractual obligation of an insolvent organization to pay any
5  refund authorized under this Section.
6  (g) Rulemaking authority to implement Public Act 95-1045,
7  if any, is conditioned on the rules being adopted in
8  accordance with all provisions of the Illinois Administrative
9  Procedure Act and all rules and procedures of the Joint
10  Committee on Administrative Rules; any purported rule not so
11  adopted, for whatever reason, is unauthorized.
12  (Source: P.A. 102-30, eff. 1-1-22; 102-34, eff. 6-25-21;
13  102-203, eff. 1-1-22; 102-306, eff. 1-1-22; 102-443, eff.
14  1-1-22; 102-589, eff. 1-1-22; 102-642, eff. 1-1-22; 102-665,
15  eff. 10-8-21; 102-731, eff. 1-1-23; 102-775, eff. 5-13-22;
16  102-804, eff. 1-1-23; 102-813, eff. 5-13-22; 102-816, eff.
17  1-1-23; 102-860, eff. 1-1-23; 102-901, eff. 7-1-22; 102-1093,
18  eff. 1-1-23; 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24;
19  103-91, eff. 1-1-24; 103-123, eff. 1-1-24; 103-154, eff.
20  6-30-23; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
21  eff. 1-1-24; 103-551, eff. 8-11-23; 103-605, eff. 7-1-24;
22  103-618, eff. 1-1-25; 103-649, eff. 1-1-25; 103-656, eff.
23  1-1-25; 103-700, eff. 1-1-25; 103-718, eff. 7-19-24; 103-751,
24  eff. 8-2-24; 103-753, eff. 8-2-24; 103-758, eff. 1-1-25;
25  103-777, eff. 8-2-24; 103-808, eff. 1-1-26; 103-914, eff.
26  1-1-25; 103-918, eff. 1-1-25; 103-1024, eff. 1-1-25; revised

 

 

  HB1085 - 27 - LRB104 05991 BAB 16024 b


HB1085- 28 -LRB104 05991 BAB 16024 b   HB1085 - 28 - LRB104 05991 BAB 16024 b
  HB1085 - 28 - LRB104 05991 BAB 16024 b
1  11-26-24.)
2  Section 95. No acceleration or delay. Where this Act makes
3  changes in a statute that is represented in this Act by text
4  that is not yet or no longer in effect (for example, a Section
5  represented by multiple versions), the use of that text does
6  not accelerate or delay the taking effect of (i) the changes
7  made by this Act or (ii) provisions derived from any other
8  Public Act.

 

 

  HB1085 - 28 - LRB104 05991 BAB 16024 b